Increased Globulin Gap And Ninteen Other Golden Rules For Fleas

Many specialties have their own nicknames. As internists, we are called fleas. Maybe because we look for too much disease; we swarm in on half dead old people looking for reasons to doctor them. One of my favorite flea action is to evaluate the globulin gap, looking specifically for an elevated or increased globulin gap.

Training to be an internist, as all internists before me can attest to is quite intense. You are responsible for the entire face of disease for old people. You have to know what you are doing. You can't fake internal medicine. We are the entry way to every possible disease known to old man. We are diagnostic specialists like no other. We are medical experts for adults.

Granny doesn't come to the emergency room complaining of third degree heart block, or acute on chronic hypercapnic respiratory failure, or hypervolemic hyponatremia, or low compliment glomerularnephritis. Granny comes to the ER with a complaint of weakness and dizziness and peeing blood. It is my job to figure it out. What to order. What not to order. Who to consult with. The ER does their thing, stabilizes unstable patients and admits those that need further evaluation. Occasionally they ask us to admit to our Hospitel. The ER's job is not to make a diagnosis. It is to exclude a diagnosis. An emergency diagnosis.

As an internist, my entire 12,000 hour + residency was built around the premise of what else could it be? What am I missing? My residency taught me exactly what to pursue and what to ignore. There is not a patient that comes and goes before me that I'm not scanning and screening and evaluating for things that just aren't right. Because I know what I know, I have high confidence in my ability to call fakers by their game or tell patients that I don't know what is going on. For that, I'm called a flea and I accept that designation with pride. If you're sick and you want answers, you go to an internist.

I can assure you, it took me more than 12,000 clinical hours to learn the human body. It is not possible to skip corners as some have suggested. Anyone making that implication is a fool. During my intense training as a resident, I learned several die hard rules of evaluation. Rules that prevent me from missing common diseases that present in uncommon ways. Rules that improve my diagnostic skills. Happy's rules read as follows.

1) Always look at the differential on a CBC. Always. Microcytic and macrocytic indices can be triggers to serious underlying conditions, some easily treatable, some not. Always look for atypical cells, abnormal differentials, eosinophils, schistocytes. Abnormal cells are always abnormal.

2) Always look for a globulin gap. The difference between your protein and albumin, when too high, can indicate an abnormal protein floating around or it could be a sign of inflammation (such as elevated CRP). Evaluation should be considered. An early diagnosis of cancer can save a lot of heart ache. A serum protein electrophoresis is a bone cancer's best friend.

3) When in doubt, order a CRP and ESR. While specific and sensitive for nothing, a normal value can be comforting and a great clue to malingering. A really high value can be a great trigger to be more aggressive in the pursuit of undiagnosed disease. The differential diagnosis of a sed rate greater than 100 is limited to osteomyelitis, vasculitis, endocarditis, lymphoma, nephrotic syndrome, connective tissue disorders and miliary TB.

4) Always look at the calcium. Correct it for your albumin. A high calcium is never normal and can cause a lot of complaints (stones, bones, moans, psychic overtones)

5) Always check a TSH when nothing makes sense. Thyroid disease is commonly under diagnosed.

6) Always look at the bicarb and calculate your anion gap. The anion gap can save lives. Just this week, I picked up an antifreeze poisoning by the anion gap. And remember MUDPILES, it will come in handy for the rest of your life.

7) When potassium replacement doesn't work, check a magnesium level.

8) When legs are swollen, always check a urinalysis for protein and an albumin level. Two under utilized tests to evaluate systemic edema. And often times a marker of undiagnosed renal disease.

9) If someone presents with renal failure, don't forget to check the CPK. Rhabomyolysis is a common but under appreciated reason for ARF. And if you see blood on a urine dipstick but no red cells on the micro, always check for rhabdo.

10) If you have elevated CPK's, always check a TSH. A common but under diagnosed cause (hypothyroidism).

11) You don't need a gastroenterologist for every case of hepatitis. 99% of nonobstructive hepatitis that I see is a medication or from fatty liver (and occasionally viral). Have your pharmacist run a med side effect profile and then sit on it. If it doesn't get better, re-evaluate

12) Knowing the baseline weight in a chronic kidney patient is imperative. You have to know your starting point to know where you're going.

13) It's ok to give as much ativan as you need for alcohol withdrawal. My record is 350 mg in a 24 hour period. Don't be afraid. You can rarely over sedate the heavy drinkers. They are machines.

14) There is no reason to call me the urine output in a 90 year old. Ever.

15) The discharge planning should begin before you admit them. Know your end point. Prepare for the unexpected and manage the expectations of the patient and family . It's rare for an old medicine patient to leave a hospital in equal or better shape than their normal base line.

16) An isolated elevated bilirubin and or a low platelet count can be an early marker for sepsis syndrome. I would draw blood cultures and empirically treat with broad spectrum antibiotics. I have picked up too many patients with sepsis based solely on an isolated elevated bilirubin (cholestasis of sepsis) or a low platelet count (a common marker of sepsis).

17) In a patient that looks sleepy and drowsy and you don't know what's going on, always consider a blood gas. You can have hypercapnea with out hypoxemia. It happens all the time. Also, in a patient with chronic elevated HCO3 on BMP, it's not a bad idea to check a blood gas  to clarify the extent of hypercapnea present.

18) If the patient is fat, they have obstructive sleep apnea until proven otherwise. Screen for it often as the morbidity associated with OSA can be huge (sudden death, CHF, arrhythmia, stroke, HTN, quality of life)

19) Don't forget venous embolism  or DVT
prophylaxis. Just about everyone the hospital should have it.

20) Know your limitations. If you don't know your limitations, you shouldn't be doing this.